Hospital Delirium (transcript)

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NARRATOR: Behind every heartbeat is a story we can learn from. As we have for over 80 years, Blue Cross and Blue Shield companies are working to use the knowledge we gain from our members to better the health of not just those we insure but all Americans. Some call it responsibility. We call it a privilege. "Second Opinion" is funded by Blue Cross Blue Shield.

NARRATOR: "Second Opinion" is produced in conjunction with UR Medicine, part of University of Rochester Medical Center, Rochester, New York.

DR. PETER SALGO: Welcome to "Second Opinion," where each week, medical experts discuss a real-life case. I'm your host, Dr. Peter Salgo. I want to thank you all in our live studio audience for being here. That's great. I want to thank you at home for tuning in, as well. Our experts today --Nathan Brummel, intensive-care-unit specialist from Vanderbilt University Medical Center. And Dr. Lou Papa, primary-care physician from the University of Rochester Medical Center. And now I'd like you to meet our special guest, Donna Smith. She's here to share her personal story of her mother.

DONNA: My mom fell three years ago at the age of 89, and we went to emergency. She had surgery in the middle of the night. She came through that surgery quite well. She was in the hospital for three days, and then she went to rehab, which she did very well with. She fell again just recently. She went in to emergency. She had surgery. She did not do well after the surgery. She had a lot of confusion. This was very unusual for her. And the first day, I thought it was the anesthesia, but as the days went on, it just got worse. And I had to keep telling everybody, "This is not my mom. This is not the way she came in to the hospital."

DR. PETER SALGO: Donna, thank you so much for joining us. It's a tough story.

DONNA: It is.

DR. PETER SALGO: Tell me a little bit about your mom. You were saying this is not your mom. What was your mom like?

DONNA: She was very articulate.

DR. PETER SALGO: Mm-hmm.

DONNA: She, um...was very bright. There was no dementia at all that I could see, and she was able to keep her checkbook. All her papers were always exactly in order. It just...She was very sharp. There was really no mental problem. There was physical -- She was feeling physically, you know, those issues.

DR. PETER SALGO: 92.

DONNA: 92. Yeah.

DR. PETER SALGO: Guys, she's 92 years old, second operation, second hip. It's not unusual for

92-year-olds to come in with fractured hips. Lou, what's going through your mind? Preoperatively, what would have gone through your mind, actually?

DR. LOU PAPA: Well, preoperatively, you know, when someone's older, you worry about a number of comorbidities as we talk about. Comorbidities are just other things that can make their course more difficult. So, certain diagnoses they have -- if they have things like dementia, if they've had strokes, if they have heart disease, what kind of medications they're on, and that kind of can predict the course of their hospitalization for many different things.

DR. PETER SALGO: Well, what impact do all of those comorbidities have on somebody going through surgery, having an anesthetic, and then coming out the other side?

DR. NATHAN BRUMMEL: Well, certainly all those medical problems that she had with her before do make her higher risk for problems afterwards because, you know, for example, if her heart was not strong, going in to the surgery, surgery can be hard on her heart and make, you know, complications afterwards.

DONNA: Well, actually, her heart -- she did end up having A-fib the first time she had the hip surgery. Other than that, we didn't know that she had a heart problem.

DR. PETER SALGO: So, I think we can say if she had A-fib after the first surgery, which is pretty common after hip surgery, and her mental status was pretty clear, it's probably not the primary actor at this point, right? So, do you have any questions for Donna at this point?

DR. NATHAN BRUMMEL: How is she different? I think that's kind of the first question. You said she wasn't your mother, or it wasn't like her.

DONNA: Because even when we went in with the broken hip, her thinking was very clear, and there was no real anxiety, which I was quite surprised. But I said to her about the anxiety, and she said, "Well, I've been through this once, so I know what to expect." And, um...

DR. LOU PAPA: Was she very -- Was there much difference between the first operation and the second one? How had she changed in that time frame prior to the first operation?

DONNA: Well, just basically physically, she was, you know, failing. She wasn't as strong. She was always a very independent person. So...she was having a little hard time adjusting to me helping her out, and...

DR. PETER SALGO: She was tough.

DONNA: Yes, she was.

DR. LOU PAPA: Was she on more medications?

DONNA: No, no, not actually. She, um... During the -- After the surgery --

DR. PETER SALGO: And they see her really postoperatively when her mental status is off. So, what did they tell you was wrong with her?

DONNA: Someone suggested my -- Okay, the first day when we noticed the confusion, we thought it was the anesthesia, but it progressively got worse – the confusion.

DR. PETER SALGO: So, what did they say was wrong? What did they think?

DONNA: Nobody really gave me an answer. One nurse, finally, about the third day in as this progressed, she said to me, "I think your mom's suffering from delirium." That was the first we'd heard about it.

DR. PETER SALGO: Before that, I know what a lot of folks say in the hospital -- 92, just had surgery, she has – and there's a word coming up here -- dementia.

DONNA: Right. Right.

DR. PETER SALGO: Did your mom have dementia?

DONNA: No, she did not.

DR. PETER SALGO: They mentioned delirium. Now, that's not dementia. What is the difference?

DR. NATHAN BRUMMEL: So, when we think of dementia, we sort of think of long-term thinking and memory problems, cognitive decline, and delirium is more of an acute syndrome. It's sort of an intense period of confusion and disorientation that comes on in people who are acutely sick.

DR. PETER SALGO: Well, how is it different than dementia? I mean, demented people are also confused.

DR. LOU PAPA: Well, it's interesting. When you listen to patients that have family members that have dementia, they very often tell you that there's something wrong with their memory. They're not remembering things, so it's very much about recall, whereas with delirium, there's really a change in who they are and how they're reacting with their environment. They're confused.

DR. PETER SALGO: So, tell me how that manifested itself. What was she like? What was she doing?

DONNA: Well, she would start throwing her arms around. She wanted us to call the police. She wanted ministration. She wanted to get out of there. [ Chuckles ] It was...

DR. PETER SALGO: "Out of there" makes sense. The rest of it...is off.

DONNA: Yeah, and trying to get up when she really shouldn't be getting up.

DR. PETER SALGO: Okay, is it more common in older people? Who else is --

DR. NATHAN BRUMMEL: It is, and we think – the way we kind of think delirium develops is, a person has sort of an underlying vulnerability, which she was showing us by having falls and that sort of thing, encounters and acute stress, like a hip fracture, like a surgery, and when those two things come together, the brain stops working normally, and people get confused and they have trouble thinking.

DR. PETER SALGO: But postoperatively, some confusion is normal.

DR. NATHAN BRUMMEL: I think that that's probably what we see is that delirium is under-recognized, that that confusion is actually delirium, but it's under-recognized. Because it's so common, we, as doctors, thought, "Hey, this is a typical thing after surgery, or after an acute illness or during an acute illness."

DR. PETER SALGO: What about your patients? When they come out of an anesthetic, some of them only have a spinal -- may not have gotten a lot of sedation.

DR. LOU PAPA: Right, and like you said, we -- I think it becomes so common. I mean, there are some studies that show it's so much as 80% of patients that all have this, so we think it's normal, but it's not really normal.

DR. PETER SALGO: How do we screen for it? Can we screen for it? Who's at risk?

DR. NATHAN BRUMMEL: Yeah. So, sort of broadly, I think hospitalized patients, people who are sick enough to need to be in the hospital, certainly age, the number of comorbidities that people have are factors that increase the risks. Certainly how sick someone is also increases the risk. And we have very good tools to screen for it. There are tools that are able to be learned by doctors and nurses that can take, you know, 1 to 2 to 5 minutes to do to screen and check people's thinking. Some of those -- One of the most common ones is called the Confusion Assessment Method. You're assessing for confusion, and that's been adapted, then, into different areas such as the intensive-care unit and into the emergency department.

DR. PETER SALGO: How many hospitals...

DR. NATHAN BRUMMEL: Yeah, it's still growing in terms of the number that are screening, that's recommended by guidelines that hospitals...

DR. PETER SALGO: That's a very safe response. It's growing. Really, what's the number? Is it more than half, less than half?

DR. NATHAN BRUMMEL: I would say it's probably less than half – probably around a third of ICUs that routinely screen for patients. And you hit on something, I think, that's important to note is that while some people have delirium and they're very agitated and moving around, most delirium is what we call "hypoactive" where people are calm, but they're very confused. Just, like, maybe only family members may notice it initially unless you use one of those screening tools.

DR. PETER SALGO: But it also means that family members are very important.

DR. NATHAN BRUMMEL: Absolutely.

DR. PETER SALGO: Is there an impact overall on survival, on postoperative course of delirium?

DR. LOU PAPA: Well, at a minimum, it's very disturbing for family. Two, it makes it very difficult to care for the patient while they're in the hospital if they think the police are coming after them. This lady just had hip surgery. It's gonna delay her recovery.

DONNA: And it did. They didn't even get her up for four days.

DR. LOU PAPA: Exactly. It keeps her in the hospital longer. It puts her at longer risk for the bad things that happen in hospitals, like infections, and they're more likely to die.

DR. PETER SALGO: More likely to die? As an independent marker for the risk of dying...

DR. NATHAN BRUMME: Right.

DR. PETER SALGO: Delirium?

DR. NATHAN BRUMMEL: Absolutely. So, just as you talked about all those things, infection and all of that, independent of all of those other things, at least in the ICU, every day that patients are delirious, that's associated with about a 10% increase in the risk of death at one year.

DR. PETER SALGO: That is a big, big risk under-recognized. And we're gonna come back and talk about that. You know, in every episode, "Second Opinion" looks for game-changers – medical innovations that could make a difference in diagnosis and treatment. In the area of hospital delirium, an innovative strategy for prevention is improving hospital care for elderly patients.

DR. SHARON BRANGMAN: Delirium in the hospital setting is an acute brain event, and it is brought on by changes in either the environment and also being very sick at the same time. So, it's very important to prevent delirium because we don't have any treatments that make it go away. The ACE team stands for Acute Care for the Elderly, and it's based on a national model that provides intensive, team-based review of older adults when they're admitted to the hospital. And we have found that the key thing, just like many conditions in medicine, is prevention. A lot of prevention has to do with simple things that are basic caregiving. You know, hospitals can be a very busy place 24 hours a day, so just ensuring that an older person can get at least 6 or 7 hours of uninterrupted sleep can be very important. It's very easy, when somebody is agitated and screaming, to order a sedative for them. Most of those sedatives aren't really helpful for an older adult, and if we can look at non-pharmacological ways of addressing their agitation, that would be very important. Sometimes it's something as simple as having a family member stay with the patient, so if they're a little confused or disoriented, if they wake up at night, they'll have a familiar face there that they can see. And so, the ACE team helps to prevent some of the things that we know can happen to older people when they're admitted to the hospital. We all take a look at the patient from our professional perspective, and we make recommendations to help increase that chance of the older person not developing delirium and leaving the hospital in good shape.

DR. PETER SALGO: Donna, your mom was 92. She had hip surgery, and she wasn't bouncing back, and she was different, and then a nurse said the word "delirium" or "hospital delirium." When you heard that, what did you do?

DONNA: I went home and looked it up.

DR. PETER SALGO: You used the reference every doctor I know uses -- Google.

DONNA: Yes, Google.

DR. PETER SALGO: And what did you learn?

DONNA: It sounded exactly like what she had, and she was going through some of the same things that I was reading, and it just totally made sense.

DR. PETER SALGO: And what did Google say to do -- that eminent medical textbook?

DONNA: Number one -- to try to keep a family member or someone that they know with them, which we did. We stayed with her 24 hours. There was always a family member with her.

DR. PETER SALGO: That was important.

DONNA: It was very important for all of us.

DR. PETER SALGO: Right. What are some other suggestions? Lou? You want to start, Lou?

DR. LOU PAPA: Yeah, I mean, the other thing is, you kind of have to review what may have triggered it.

So, common things, you know, infections -- making sure they don't have a source of infection that's triggered it. A lot of it is doctor-induced. You know, there's medications we started the patients on that can trigger it. They're attached to a number of things they've never been attached to before. The room is different. It's a noisy place. The sensory input's different. There's a lot of things that add fuel to the fire.

DR. PETER SALGO: But there's simple stuff, too. I mean, sometimes the drugs can be modified to work better, or drugs that will lessen the risk of delirium, but there's some simple stuff.

DR. NATHAN BRUMMEL: Right, like having a family member around to reorient and reassure, getting people up and having them move around, not just confining them.

DONNA: Which I had to really push for because she was not getting... Well, I think because the heart issue, they were concerned with that, so they weren't getting her up because the previous time she was up the next day.

DR. PETER SALGO: Okay.

DONNA: This time, it went in to almost the fourth day, and I said, "Please, please, just get her up, even if only for a couple of steps," which they did, but they had to use a machine to get her up, of course.

DR. PETER SALGO: But there's other stuff, too. You want to reorient them to their environment. Simple stuff -- glasses?

DR. NATHAN BRUMMEL: Absolutely.

DONNA: Oh, yes. Yes.

DR. NATHAN BRUMME: Glasses, hearing aids, a clock that they can see, a calendar that tells them what day it is.

DONNA: And we did that.

DR. LOU PAPA: And back when I was a resident, it wasn't unusual when patients came to the hospital. They took their teeth, they took their hearing aids, and they took their glasses so they wouldn't lose them, but in the meantime, they were completely disoriented.

DR. PETER SALGO: All of these things are important -- family photos. Did you play music?

DONNA: No, we didn't. I kind of wish we had. I didn't think of that. You know, I just...

DR. PETER SALGO: Specifically for people who are very...

DONNA: Agitated.

DR. PETER SALGO:...music-oriented, that often helps, too. So, with all of that, were you pleased that you were at least an advocate?

DONNA: Yes. Oh, absolutely. Yeah.

DR. PETER SALGO: Well, your brother's here in the audience. We're gonna talk with him, too. Fred, Donna's brother, what was this like for you? What was it like when your mom was in the hospital and experiencing all this?

FRED: Well, I think Donna's pretty well summarized the feelings of the family. It was like a roller coaster for us. We didn't know what to expect each time we went in. And, you know, we would be having a rational conversation, or what appeared to be a rational conversation, and then we'd suddenly veer off into left field. And so, we were always trying to bring her back. We were just constantly trying to bring her back each time. The family communicated with each other. Each time one of us left her, we would communicate with the other, and we'd know what was going on prior to our being there, and then, we tried to pick up where they left off, and just keep her going. And you asked Donna about the music, and my mother loved listening to the talk show on the radio. So, we did bring a radio in and let her listen to her talk show, and I think that was somewhat helpful, but it was just a piece of putting the puzzle back together.

DR. PETER SALGO: It's a big puzzle and a big problem.

FRED: Yeah.

DR. PETER SALGO: You know, I want to turn back to my colleagues over here because researching this, listening to this, and thinking back over my career, when I said it earlier, "Well, that's normal, isn't it?" It's not, but there is medical slang...

DR. NATHAN BRUMMEL: Right.

DR. PETER SALGO: ...medical lingo for this sort of thing. The one that pops into my mind is "sundowning."

DR. NATHAN BRUMMEL: Absolutely.

DR. PETER SALGO: You know, we say, "Oh, she's 92, and she's sundowning." What was that?

DONNA: Terrible. She didn't do well because her mental status was just... not there.

DR. PETER SALGO: So, it persisted. She's out of the hospital, but she still has delirium. And then from rehab, where did she go?

DONNA: We were looking -- Well, she started to do a little bit better, and we were looking in to some assisted-care facilities, and she wasn't ready to be -- They would only do four weeks. She wasn't ready to leave, so we decided to take her up to the nursing facility...

DR. PETER SALGO: Okay.

DONNA: ...until we could get her back on track.

DR. PETER SALGO: Okay.

DONNA: ...in which we did. After we got a speech therapist for a while, she did pretty well.

DR. PETER SALGO: So, she got therapy, she became -- she came back to you. All the way back?

DONNA: No. I'd say about 80%.

DR. PETER SALGO: All right. She says her mom got therapy. What is effective therapy for delirium, Lou?

DR. LOU PAPA: Well, I think a lot of things, it depends on what their deficits are. I mean, getting up and moving them around, if they've been bed-bound, working on speech therapy, working on occupational therapy -- anything that returns some functionality back 'cause that lack of functionality is another interaction with their environment that affects their ability to be focused.

DR. PETER SALGO: The word that comes to my mind is "reintegration."

DR. NATHAN BRUMMEL: Right.

DR. PETER SALGO: Back into the environment in which you were comfortable. So, if we need to do all that, and that's a lot of work, and it didn't work 100%, why don't we look at ways to prevent it in the first place?

DR. NATHAN BRUMMEL: Right, and so, that's actually what we know, is that delirium's much easier to

prevent than it is to treat once it's there.

DR. PETER SALGO: So, you can prevent it?

DR. NATHAN BRUMMEL: In some cases. So, there's a program called the Hospital Elder Life Program, one of the most well-known and successful programs in terms of preventing delirium in hospital. Basically, what it consists of is getting people up, mobilizing them, moving them around, taking them for a walk while they're in the hospital, making sure they have adequate nutrition, ensuring good sleep so things like turning off the TV at night, avoiding caffeinated beverages, those kinds of things.

DR. PETER SALGO: Turning off the lights at night.

DR. NATHAM BRUMMEL: Turning off the lights at night.

DR. PETER SALGO: Turning down the alarms.

DR. NATHAN BRUMMEL: Right.

DR. PETER SALGO: Right?

DR. NATHAN BRUMMEL: Right. All of those things have been shown to be helpful in preventing delirium.

DR. LOU PAPA: There's good data that shows that if you have those preventative tools, then you employ them, that you really do reduce the episodes of delirium.

DR. NATHAN BRUMMEL: You can reduce delirium or the development of delirium. Now, once it's present, that's a much tougher nut to crack.

DR. NATHAN BRUMMEL: Right, so in the ICU, the risk factors are a little bit different than someone who's outside of the ICU. We give people a lot of sedation and other psychoactive medicines -- medicines that can cause people to be confused. We also think they're too sick to get up and move around. So, we've learned that by reducing medicines, such as benzodiazepines --

DR. PETER SALGO: The benzodiazepines are like Valium, Ativan?

DR. NATHAN BRUMMEL: Exactly, those medicines. Reducing those, using other medicines of patients that need sedation, treating pain, getting people up and moving them around actually reduces delirium in the ICU, and actually saves lives in the hospital.

DR. PETER SALGO: What number are we looking at when you say it reduces? From what to what?

DR. NATHAN BRUMMEL: From -- It reduces in the ballpark of 30% to 50% of the number of days that people are delirious while they're in the ICU.

DR. PETER SALGO: Big-time change. There are also some subtle changes doctors can do because there are some antihypertensive drugs which can provoke delirium or contribute to it. So, less sedation, but people are using sedation 'cause your mom, for example, was waving her arms. She was excitable.

DONNA: Oh, yeah.

DR. PETER SALGO: And the response is, "Oh, let's give her some benzodiazepine."

DONNA: They did do a few trial, and then when I read the articles, I asked to please just try to eliminate them as much as they can.

DR. PETER SALGO: So, the idea would be to keep the drugs to a minimum, keep them as awake as possible, keep them oriented. This is what I'm hearing from you.

DR. NATHAN BRUMMEL: Right.

DR. PETER SALGO: All of these things now well established. There's good research. Here's a number. Of all the ICUs across the nation, what percent are actually doing it right?

DR. NATHAN BRUMMEL: I'd say about a third.

DR. PETER SALGO: Two-thirds aren't?

DR. NATHAN BRUMMEL: Right.

DR. PETER SALGO: Unacceptable. You would agree?

DONNA: Yes.

DR. PETER SALGO: What do we do? How do we make this... How do we make an imprint on American medicine to say, "No, sundowning, delirium not normal. Fix it."

DR. NATHAN BRUMMEL: Well, I think one is getting that message out -- that it's not normal. It's abnormal, and we should think about it. The hard part is that there's no single medicine we can give. You know, we like to have a medicine we can give for something, but as we've talked about it, it's all these different things that are hard to implement on a grand scale because they require lots of thinking and lots of people to...

DR. LOU PAPA: I mean, imagine -- I mean, I'm sure doctors don't want to have patients delirious. It's very intensive for the doctors, and I think a lot of times they use the drugs 'cause they're medicating themselves 'cause it's more comfortable for them not to see you delirious, but a lot of it's just a manpower thing. It requires people to walk, and it requires people to get them out of bed. It requires regular intervention on the patient. I imagine that's one of the big barriers to it.

DR. PETER SALGO: Now, Donna, with all the work you did, with all the reorienting that you did and your mom came back to you, the story didn't end quite as well as you would've liked. Tell us about that.

DONNA: [ Sniffling ] She got -- caught something that was going around in the nursing facility, I think. And she passed away.

DR. PETER SALGO: Painful. Awful.

DONNA: It was. It was. You know, I know she was -- She turned 93 the day after she passed away. And, you know, I mean... Something was going to give sooner or later -- we understand that -- but it was just the way it all happened, you know? It just felt helpless and wish I could've done more for her.

DR. PETER SALGO: I think we can say... hearing your story, that you did everything -- more than everything that you could.

DONNA: When I look back, I know I did, but it's just -- you still feel like you never did enough.

DR. PETER SALGO: She's your mom.

DONNA: That's true.

DR. PETER SALGO: Well, I'm so glad that you had the courage to join us here and share this, and I think we can all say that if we can help other folks who have seen...

DONNA: Oh, that's fine. I want you to -- ask if you could do this because I think it's so important that people who don't have family members who are as close as ours, they go in and this happens, and there's nobody, really, to advocate for them, so... If they could get at it sooner, I mean, if we had addressed it a little bit sooner, we might've gotten further ahead, but...you don't know until you've been through it once.

DR. PETER SALGO: You just don't know.

DONNA: No.

DR. PETER SALGO: Well, first of all, clearly a more caring family I don't think I've ever seen. Second, I want to thank you for being here. This obviously isn't easy for you, and sharing your story with us, I think, is important. So, to end our show today, I know you've got some advice to families that you'd like to share.

DONNA: One of the problems with when an elderly person goes into a hospital, I think, immediately people think there's some dementia, especially if they're in their late -- early 80s or 90s, and I think that's what was assumed with my mom. And they really don't know. They have no idea 'cause they don't know the person, so they don't know whether she has any dementia going on. So, I think that needs to be really addressed when someone goes in to a hospital. And I think if anybody has an elective surgery, they know they're going in, you want to do a little research and kind of know the things to look for, the precautions to take before having the surgery. And if it's an emergency surgery, I think the family members -- it'd be nice if they kind of had an idea of what to look for and the steps to take and to make sure that they make known, their family member, what their mental status is when they go in.

DR. PETER SALGO: I want to thank all of you so much for being here in our live studio audience. I want to thank you at home for watching, as well. Remember, you can get more second opinions and patient stories at our website at secondopinion-tv.org. And you can continue this conversation on Facebook and Twitter where we are live every day with health news. I'm Dr. Peter Salgo. I'll see you next time for another "Second Opinion."

NARRATOR: Behind every heartbeat is a story we can learn from. As we have for over 80 years, Blue Cross and Blue Shield companies are working to use the knowledge we gain from our members to better the health of not just those we insure but all Americans. Some call it responsibility. We call it a privilege. "Second Opinion" is funded by Blue Cross Blue Shield.

NARRATOR: "Second Opinion" is produced in conjunction with UR Medicine, part of University of Rochester Medical Center, Rochester, New York.

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